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ii39
BTS guidelines for the management of spontaneous
pneumothorax
M Henry, T Arnold, J Harvey, on behalf of the BTS Pleural Disease Group, a subgroup
of the BTS Standards of Care Committee
.............................................................................................................................
Thorax 2003;58(Suppl II):ii39–ii52
1 INTRODUCTION airway obstruction, mediated by an influx of
Pneumothorax is defined as air in the pleural inflammatory cells, often characterises pneumo-
space—that is, between the lung and the chest thorax and may become manifest in the smaller
wall.1 Primary pneumothoraces arise in otherwise airways of men at an earlier stage.12 Patients with
healthy people without any lung disease. Second- primary pneumothoraces tend to be taller than
ary pneumothoraces arise in subjects with under- control patients.13 14 The gradient in pleural
lying lung disease. The term pneumothorax was pressure increases from the lung base to the
first coined by Itard, a student of Laennec, in apex,1 thus alveoli at the lung apex in tall
1803,2 and Laennec himself described the clinical individuals are subject to significantly greater
picture of pneumothorax in 1819.2 He described distending pressure than those at the base of the
most pneumothoraces as occurring in patients lung and, theoretically, are more predisposed to
with pulmonary tuberculosis, although he recog- the development of subpleural blebs.15 Strong
nised that pneumothoraces also occurred in emphasis should be placed on the relationship
otherwise healthy lungs, a condition he described between smoking and pneumothorax in an effort
as “pneumothorax simple”. The modern descrip- to deter those smokers who have developed a
tion of primary spontaneous pneumothorax pneumothorax from smoking. Despite the appar-
occurring in otherwise healthy people was pro- ent relationship between smoking and pneumo-
vided by Kjaergard in 1932.3 Primary pneumotho- thorax, 80–86% of young patients continue to
rax remains a significant global problem, occur- smoke after their first primary pneumothorax.16
ring in healthy subjects with a reported incidence The risk of recurrence of primary pneumothorax
of 18–28/100 000 per year for men and 1.2–6/ is 54% within the first 4 years, with isolated risk
100 000 per year for women.4 5 Secondary pneu- factors including smoking, height in male
mothorax is associated with underlying lung dis- patients,14 17 and age over 60 years.17 Risk factors
ease, whereas primary pneumothorax is not. By for secondary pneumothorax recurrence include
definition, there is no apparent precipitating age, pulmonary fibrosis, and emphysema.17 18
event in either. Hospital admission rates for com- In an effort to standardise treatment of
bined primary and secondary pneumothorax are primary and secondary pneumothoraces, the
reported in the UK at between 5.8/100 000 per British Thoracic Society (BTS) published guide-
year for women and 16.7/100 000 per year for lines for the treatment of both in 1993.19 Several
men. Mortality rates in the UK were 0.62/million studies suggest that compliance with the 1993
per year for women and 1.26/million per year for guidelines, though improving, remains at only
men between 1991 and 1995.6 This guideline 20–40% among non-respiratory and A&E
describes the management of spontaneous pri- staff.20–22 Clinical guidelines have been shown to
mary and secondary pneumothorax. It excludes improve clinical practice23 24; compliance with
the management of trauma. Algorithms for the guidelines is related to the complexity of practical
management of spontaneous primary and sec- procedures that are described25 and is strength-
ondary pneumothorax are shown in figs 1 and 2. ened by an evidence base.26 Steps in the 1993
• Strong emphasis should be placed on the guidelines which may need clarification include:
relationship between the recurrence of (1) simple aspiration (thoracocentesis) versus
pneumothorax and smoking in an effort intercostal tube drainage (tube thoracostomy) as
to encourage patients to stop smoking. the first step in the management of primary and
[B] secondary pneumothoraces, (2) treatment of eld-
Despite the absence of underlying pulmonary erly pneumothorax patients or patients with
disease in patients with primary pneumothorax, underlying lung disease, (3) when to refer
subpleural blebs and bullae are likely to play a role patients with a difficult pneumothorax to a chest
in the pathogenesis since they are found in up to physician or thoracic surgeon for persistent air
90% of cases of primary pneumothorax at thora- leak or failure of re-expansion of the lung, and (4)
coscopy or thoracotomy and in up to 80% of cases treatment of the recurrent pneumothorax. This
on CT scanning of the thorax.7 8 The aetiology of guideline addresses these issues. Its purpose is to
See end of article for such bullous changes in otherwise apparently provide a comprehensive evidence based review
authors’ affiliations healthy lungs is unclear. Undoubtedly, smoking of the epidemiology, aetiology, and treatment of
....................... pneumothorax to complement the summary
plays a role9–11; the lifetime risk of developing a
Correspondence to: pneumothorax in healthy smoking men may be guidelines for diagnosis and treatment.
Dr M Henry, The General as much as 12% compared with 0.1% in non-
Infirmary at Leeds, Great smoking men.11 This trend is also present, though 2 CLINICAL EVALUATION AND IMAGING
George Street, Leeds
LS1 3EX, UK; to a lesser extent, in women.11 There does not • Expiratory chest radiographs are not rec-
michael.henry@leedsth.nhs.uk appear to be any relationship between the onset ommended for the routine diagnosis of
. . . . . . . . . . . . . . . . . . . . . . . of pneumothorax and physical activity.5 Small pneumothorax. [B]
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ii40 Henry, Arnold, Harvey
Primary
pneumothorax
Start
Breathless and/or rim of air > 2 cm NO
on chest radiograph ?
(section 4.1)
YES
Aspiration
YES
?Successful
(section 4.2)
NO
Consider repeat
aspiration
YES
?Successful
(section 4.2.1)
NO
Intercostal drain
Remove 24 hours after
YES
?Successful full re-expansion/cessation
(section 4.3) of air leak without clamping
NO
Referral to chest physician within 48 hours
Consider
?Suction (section 4.4.1)
discharge
Referral to thoracic surgeon (section 4.6)
after 5 days (section 4.5)
Figure 1 Recommended algorithm for the treatment of primary pneumothorax.
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BTS guidelines for the management of spontaneous pneumothorax ii41
Secondary
pneumothorax
Start
Aspiration
Breathless + age > 50 years NO
+ rim of air > 2 cm
?Successful
(section 4.2)
on chest radiograph ?
(section 4.1)
NO
YES YES
Intercostal drain
Admit to
hospital for
?Successful
24 hours
(section 4.3) YES
NO
Referral to chest
physician after 48 hours Remove 24 hours after Consider
YES
?Suction (section 4.4.1) full re-expansion/cessation discharge
of air leak (section 4.6)
?Successful
NO
Early discussion with
surgeon after 3 days
(section 4.5)
Figure 2 Recommended algorithm for the treatment of secondary pneumothorax.
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ii42 Henry, Arnold, Harvey
• A lateral chest or lateral decubitus radiograph methods of estimating size from PA chest radiographs are
should be performed if the clinical suspicion of cumbersome and generally used only as a research tool.42 The
pneumothorax is high, but a PA radiograph is size of a pneumothorax, in terms of volume, is difficult to
normal. [B] assess accurately from a chest radiograph which is a two
• CT scanning is recommended when differentiating a dimensional image. In the 1993 guidelines19 pneumothoraces
pneumothorax from complex bullous lung disease, were classified into three groups:
when aberrant tube placement is suspected, and • “small”: defined as a “small rim of air around the lung”;
when the plain chest radiograph is obscured by • “moderate”: defined as lung “collapsed halfway towards
surgical emphysema. [C] the heart border”; and
• The clinical history is not a reliable indicator of • “complete”: defined as “airless lung, separate from the dia-
pneumothorax size. [C] phragm”.
Clinical history and physical examination usually suggest the This attempt to quantify a pneumothorax tends to underesti-
presence of a pneumothorax, although clinical manifestations mate the volume of anything greater than the smallest of
are not reliable indicators of size.29 30 In general, the clinical pneumothoraces.1 Since the volume of a pneumothorax
symptoms associated with secondary pneumothoraces are approximates to the ratio of the cube of the of the lung diam-
more severe than those associated with primary pneumotho- eter to the hemithorax diameter, a pneumothorax of 1 cm on
races, and most patients with a secondary pneumothorax the PA chest radiograph occupies about 27% of the hemithorax
complain of breathlessness which is out of proportion to the volume if the lung is 9 cm in diameter and the hemithorax
size of the pneumothorax.31 32 Many patients, particularly 10 cm: (103 – 93)/103 = 27%. Similarly, a 2 cm radiographic
those with primary pneumothoraces, do not seek medical pneumothorax occupies 49% of the hemithorax on the same
advice for several days, 46% waiting more than 2 days with basis (fig 3).
symptoms.9 This feature is important because the occurrence In view of the proximity of the lung surface to the chest wall
of re-expansion pulmonary oedema (RPO) after re-inflation in a pneumothorax of <1 cm, aspiration using a sharp needle
may be related to the length of time the lung has been may not be advisable. However, given that the actual volume of
collapsed (see section 4.4.1).33 34 a 2 cm pneumothorax approximates to a 50% pneumothorax,
Arterial blood gas measurements are frequently abnormal this should be considered large in size and can be treated
in patients with pneumothorax with the arterial oxygen ten- safely by aspiration when circumstances dictate. For the pur-
sion (PaO2) being less than 10.9 kPa (80 mm Hg) in 75% of poses of these new guidelines, “small” is therefore regarded as
patients.35 The presence of underlying lung disease along with a pneumothorax of <2 cm and “large” as a pneumothorax of
the size of pneumothorax predicts the degree of >2 cm.
hypoxaemia.35 Arterial PaO2 was below 7.5 kPa (55 mm Hg) If accurate size estimates are required, CT scanning is the
and PaCO2 above 6.9 kPa (50 mm Hg) in 16% of cases of most robust approach.43 Otherwise, it is only recommended for
secondary pneumothorax in the largest reported series.36 Pul- difficult cases such as patients in whom the lungs are obscured
monary function tests are weakly sensitive measures of the by overlying surgical emphysema, or to differentiate a
presence or size of pneumothorax and are not pneumothorax from a suspected bulla in complex cystic lung
recommended.8 disease.44 The routine use of CT scans preoperatively in
In both primary and secondary spontaneous pneumothorax patients with pneumothorax and suspected emphysema or
the diagnosis is normally established by plain chest radio- isolated bullae adds little to the plain PA chest radiograph
graphy. In general, expiratory radiographs add little and are from the point of view of management of the patient.45
not indicated as a routine investigation, even in the case of a
suspected small apical pneumothorax.37 38 When a pneumo-
4 TREATMENT OPTIONS FOR SPONTANEOUS
thorax is suspected but not confirmed by standard postero-
anterior (PA) chest radiographs, lateral radiographs provide PNEUMOTHORAX
added information in up to 14% of cases.39 The lateral decubi- 4.1 Observation
tus radiograph is superior to the erect or supine chest • Observation should be the treatment of choice for
radiograph and is felt to be as sensitive as CT scanning in small closed pneumothoraces without significant
pneumothorax detection.40 The upright lateral or lateral decu- breathlessness. [B]
bitus radiograph is clinically helpful where findings on the • Patients with small (<2 cm) primary pneumothora-
upright PA radiograph are unclear. While such small ces not associated with breathlessness should be
pneumothoraces may not have much clinical relevance in considered for discharge with early outpatient
patients without underlying lung disease, in patients with review. These patients should receive clear written
suspected secondary pneumothoraces, even small pneumo- advice to return in the event of worsening breathless-
thoraces may have significant implications and here lateral or ness. [B]
lateral decubitus radiographs are probably valuable. In
patients with severe bullous lung disease CT scanning will dif-
ferentiate emphysematous bullae from pneumothoraces and
save the patient an unnecessary and potentially dangerous
aspiration.41
1993:
Small secondary pneumothorax
Tx suggested: simple
aspiration
3 SIZE OF PNEUMOTHORAX
• The previous classification of the size of a pneumo- 2003:
Volume_of pneumothorax
thorax tends to underestimate its volume. In these 9.5 cm (123 9.53) /123 = 50%
new guidelines the size of a pneumothorax is divided Tx suggested: intercostal tube
into “small” or “large” depending on the presence of 12 cm drainage
a visible rim of <2 cm or >2 cm between the lung
margin and the chest wall.
The plain PA radiograph is a poor method of quantifying the Figure 3 Quantitation of size of pneumothorax: 1993 versus 2003
size of a pneumothorax as it usually underestimates it. Exact guidelines.
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BTS guidelines for the management of spontaneous pneumothorax ii43
• If a patient with a pneumothorax is admitted there is complete collapse of the lung, and in smaller primary
overnight for observation, high flow (10 l/min) oxy- pneumothoraces in which patients complain of significant
gen should be administered, with appropriate cau- breathlessness. Simple aspiration was also recommended as
tion in patients with COPD who may be sensitive to initial treatment in secondary pneumothoraces where there is
higher concentrations of oxygen. [B] moderate or complete collapse of the lung and in smaller sec-
• Breathless patients should not be left without inter- ondary pneumothoraces where significant breathlessness is
vention regardless of the size of the pneumothorax present. Small was defined as a “small rim of air around the
on a chest radiograph. [C] lung”, moderate as “lung collapsed halfway towards the heart
border”, and complete as “airless lung, separate from the dia-
4.1.1 Primary pneumothoraces, minimal symptoms phragm”.
Observation alone is advised for small, closed, mildly sympto- A study describing treatment practices for pneumothoraces
matic spontaneous pneumothoraces.21 30 46–48 70–80% of pneu- after the 1993 guidelines showed that only 17 of 43 decisions
mothoraces estimated at smaller than 15% have no persistent to aspirate pneumothoraces by A&E staff, perhaps because of
air leak and recurrence in those managed with observation unfamiliarity with the technique, and nine of 26 similar deci-
alone is less than in patients treated with intercostal tube sions made by medical staff seemed appropriate.20 A similar
drainage.48 Patients with small primary pneumothoraces and study undertaken in Scotland and completed before the pub-
minimal symptoms do not require hospital admission, but it lication of the 1993 guidelines reported that only three of 38
should be stressed before discharge that they should return spontaneous pneumothoraces (one primary, two secondary)
directly to hospital in the event of developing breathlessness. were treated initially by aspiration alone and all three were
Most patients in this group who fail this “treatment” and successful.21 It would seem, therefore, that many medical staff
require intercostal tube drainage have secondary are unaware of the guidelines in this respect, or are unwilling
pneumothoraces.48 or unable to aspirate.
Successful re-expansion of the lung is less likely after sim-
4.1.2 Secondary pneumothoraces, minimal symptoms
ple aspiration in secondary pneumothorax (33–67%) than in
Observation alone is only recommended in patients with small
primary (59–83%).51–53 However, several larger series which
secondary pneumothoraces of less than 1 cm depth or isolated
used this technique found that 59–73% of all pneumothoraces
apical pneumothoraces in asymptomatic patients. Hospitalisa-
requiring intervention could be successfully aspirated.51 52 54–56
tion is recommended in these cases. All other cases will
require active intervention (aspiration or chest drain inser- Successful aspiration in these series depended on age (under
tion, see later sections). 50 years: 70–81% success, over 50 years: 19–31% success), the
presence of chronic lung disease (27–67% success), and the
4.1.3 Symptomatic pneumothoraces, primary or size of the pneumothorax (<3 l aspirated: 89% success, >3 l:
secondary no success; >50% on chest film: 62% success, <50% on chest
Observation alone is inappropriate and active intervention is film: 77% success). In a prospective randomised trial to com-
required. Marked breathlessness in a patient with a small pare simple aspiration and tube drainage of pneumothoraces,
(<2 cm) primary pneumothorax may herald tension Andrivert and colleagues55 found a 20% recurrence rate at 3
pneumothorax.48 If a patient is hospitalised for observation, months after simple aspiration of primary pneumothoraces
supplemental high flow (10 l/min) oxygen should be given and a 28% recurrence rate after tube drainage demonstrating
where feasible.49 Inhalation of high concentrations of oxygen that simple aspiration is no less effective from the point of
may reduce the total pressure of gases in pleural capillaries by view of recurrence than the more invasive intercostal tube
reducing the partial pressure of nitrogen. This should increase drainage. In a more recent randomised controlled trial Noppen
the pressure gradient between the pleural capillaries and the and coworkers53 showed that simple aspiration was as
pleural cavity, thereby increasing absorption of air from the successful in treating first primary pneumothoraces as imme-
pleural cavity. The rate of resolution/reabsorption of spontane- diate intercostal tube drainage (59% versus 63%). Patients
ous pneumothoraces is 1.25–1.8% of the volume of hemi- treated with simple aspiration were less likely to be hospital-
thorax every 24 hours.47 50 In a group of 11 patients with ised and less likely to suffer a recurrence of the pneumothorax
pneumothoraces ranging in size from 16% to 100%, the mean over the next 12 months. Harvey and Prescott,56 on behalf of
rate of re-expansion was 1.8% per day and full re-expansion the British Thoracic Society, confirmed that simple aspiration
occurred at a mean of 3.2 weeks.47 A 15% pneumothorax of primary pneumothoraces is as effective as tube drainage
would therefore take 8–12 days to resolve fully. The addition of
when recurrence of pneumothorax at 12 months was taken as
high flow oxygen therapy has been shown to result in a four-
an end point. Further advantages of simple aspiration over
fold increase in the rate of pneumothorax reabsorption during
intercostal tube drainage are a reduction in total pain scores
periods of oxygen supplementation.49
during hospitalisation and shorter hospital stays.56 In centres
4.2 Simple aspiration where the experience and equipment is available, considera-
tion should be give to using small bore catheter aspiration kits
• Simple aspiration is recommended as first line treat-
(CASP, see below) to aspirate pneumothoraces as the catheter
ment for all primary pneumothoraces requiring
may be left in place until full re-expansion of the lung is con-
intervention. [A]
firmed. Otherwise, repeat aspiration or connection to an
• Simple aspiration is less likely to succeed in second- underwater seal system may be facilitated through these
ary pneumothoraces and, in this situation, is only indwelling small bore catheters.
recommended as an initial treatment in small Large secondary pneumothoraces (>2 cm), particularly in
(<2 cm) pneumothoraces in minimally breathless patients over the age of 50, should be considered a high risk of
patients under the age of 50 years. [B] failure for simple aspiration and recurrence and therefore tube
• Patients with secondary pneumothoraces treated drainage is recommended as appropriate initial treatment. If
successfully with simple aspiration should be admit- simple aspiration is considered in patients with secondary
ted to hospital and observed for at least 24 hours pneumothoraces, admission for observation for at least 24
before discharge. [C] hours should be undertaken, with prompt progression to tube
The 1993 BTS guidelines19 recommended simple aspiration as drainage if needed. Active treatment of the underlying lung
first line treatment in all primary pneumothoraces where disorder will also be necessary.
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ii44 Henry, Arnold, Harvey
4.2.1 Repeat aspiration and catheter aspiration of simple after 24 hours whether the tube is clamped or not before
pneumothorax removal.80 However, many experienced physicians still support
• Repeated aspiration is reasonable for primary pneu- the use of clamping of chest drains before their removal to
mothorax when the first aspiration has been unsuc- detect small air leaks not immediately obvious at the bedside.
cessful (i.e. patient still symptomatic) and a volume By clamping the chest drain for several hours and performing
of <2.5 l has been aspirated on the first attempt. [B] a chest radiograph, a minor or intermittent air leak may be
detected, potentially avoiding the need for chest tube reinser-
• Catheter aspiration of pneumothorax (CASP) can be tion. In the ACCP Delphi consensus statement65 about half the
used where the equipment and experience is avail- consensus group supported clamping and half did not, and
able. [B] this seems similar to the UK spread of opinion. Drain clamp-
• Catheter aspiration kits with an integral one way ing is therefore not generally recommended for safety reasons,
valve system may reduce the need for repeat aspira- but is acceptable under the supervision of nursing staff who
tion. [C] are trained in the management of chest drains and who have
Failure to re-expand a primary pneumothorax with aspiration instructions to unclamp the chest drain in the event of any
can be successfully corrected by a second aspiration in over clinical deterioration. Patients with a clamped chest drain
one third of cases, particularly where the initial attempt failed inserted for pneumothorax should not leave the specialist
because of a kinked or displaced catheter.51 Despite this, the ward area.
tendency is to treat aspiration failures with tube Despite these risks, tube drainage remains an effective
drainage.20 51 52 A second attempt at simple aspiration of the treatment for pneumothorax although it is not proven that
pneumothorax should be considered unless >2.5 l was tube drainage should be performed as the initial treatment in
aspirated during the unsuccessful first attempt.56 Catheter any pneumothorax. Simple aspiration should be considered as
aspiration of simple pneumothorax (CASP) involves a small the primary treatment for all primary pneumothoraces
(8 F) catheter being passed over a guidewire into the pleural requiring intervention but not considered to be under tension.
space. A three way stopcock is attached and air may be In secondary pneumothoraces in patients over 50 years with
aspirated via a 50 ml syringe. This controls up to 59% of all pneumothorax >50%, primary failure rates for aspiration are
pneumothoraces. Addition of a Heimlich valve and suction estimated at >50%.51 52 66 Age alone is a strong predictor of
may improve success rates further.57–59 failure of simple aspiration (>50 years, success 27–67%),51 52
although in those over the age of 50 years with no evidence of
4.3 Intercostal tube drainage pre-existing lung disease there is no evidence that tube drain-
• If simple aspiration or catheter aspiration drainage age should be recommended before simple aspiration as
of any pneumothorax is unsuccessful in controlling primary treatment.
symptoms, then an intercostal tube should be Analgesic use during the insertion of intercostal tubes
inserted. [B] remains poorly studied. The injection of intrapleural local
anaesthetic (20–25 ml = 200–250 mg, 1% lignocaine) given as
• Intercostal tube drainage is recommended in second- a bolus and at eight hourly intervals as necessary after the
ary pneumothorax except in patients who are not insertion of the drain significantly and safely reduced pain
breathless and have a very small (<1 cm or apical) scores without affecting blood gas measurements, either with
pneumothorax. [B] or without chemical pleurodesis. There are no data detailing
• A bubbling chest tube should never be clamped. [B] the incidence of pleural infection with this technique.67 68
• A chest tube which is not bubbling should not usually Chest tubes frequently (59%) end up in fissures,69 but these
be clamped. [B] tubes seem to retain their effectiveness. Step by step
guidelines to chest drain insertion are described elsewhere in
• If a chest tube for pneumothorax is clamped, this
these guidelines (page ii53).
should be under the supervision of a respiratory phy-
sician or thoracic surgeon, the patient should be
4.3.1 Complications of intercostal tube drainage
managed in a specialist ward with experienced nurs-
The complications of intercostal tube drainage include
ing staff, and the patient should not leave the ward
penetration of the major organs such as lung, stomach, spleen,
environment. [C]
liver, heart and great vessels, and are potentially fatal.63 70–73
• If a patient with a clamped drain becomes breathless These complications occur more commonly when a sharp
or develops subcutaneous emphysema, the drain metal trocar is inappropriately applied during the
must be immediately unclamped and medical advice procedure.63 72 73
sought. [C] In the largest series reviewing complications of tube drain-
Underwater seal drainage using a chest tube was introduced age in recent times, Chan and colleagues74 identified
in 1875.60 Widespread closed tube drainage was first adopted complications in 18% of chest drain insertions for all
during the 1917 influenza epidemic.61 Intercostal tube indications; 64% of these chest tubes (n=373) were inserted
drainage or underwater seal drainage in its modern form has for treatment of pneumothorax. However, 15% of the “compli-
been in use since 1916 when Kenyon62 described a “siphon” cations” identified involved failure of resolution of the
method of draining traumatic haemothorax. This treatment, pneumothorax and only 4% involved aberrant tube place-
despite being extremely effective, has many potential disad- ment. Notably, complications related to tube placement
vantages ranging from chest and abdominal visceral trauma occurred most commonly on medical wards. CT assessment
from sharp trocars in the hands of inexperienced operators63 to suggests a higher rate of incorrect tube placement. Baldt and
the bulkiness of the underwater seal bottle system which must colleagues75 identified 3% of tubes placed extrathoracically
be kept upright. and 6% placed within the lung during the treatment of pneu-
Likewise it may be hazardous to clamp a chest drain that is mothoraces. This highlights the need for correct training in
still bubbling, thereby potentially converting simple pneumo- chest tube placement. In some circumstances, thoracic CT
thoraces into life threatening tension pneumothoraces.64 Such scanning is valuable for assessing chest tube position—for
instances are anecdotal, and there is no evidence of which we example, when misplacement is suspected but not confirmed
are aware that clamping the tube improves success rates or on a plain radiograph.75
prevents recurrence. Almost identical success rates have been Pleural infection is another complication of intercostal tube
recorded for the maintenance of full re-expansion of the lung drainage. The rate of empyema after chest tube insertion has
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BTS guidelines for the management of spontaneous pneumothorax ii45
been estimated as 1%.74 Other series have reported an piratory physician. Such patients may require sustained chest
incidence of up to 6% of chest tube related empyema in drainage with complex drain management (suction, chest
trauma cases and suggested that the administration of drain repositioning) and thoracic surgery decisions. These
prophylactic antibiotics should be considered, particularly issues will be better managed by physicians with specific
where a prolonged period of chest tube drainage might be training and experience in these problems and established
anticipated.76 77 This highlights the need for full aseptic relationships with a thoracic surgeon. Drain management is
technique in the insertion or manipulation of any chest drain- also best delivered by nurses with substantial experience in
age system. this area.
Finally, surgical emphysema is a well recognised complica-
tion of intercostal tube drainage.78 This is generally of cosmetic 4.4.1 Chest drain suction
importance only, subsiding after a few days. The development • Suction to an intercostal tube should not be applied
of surgical emphysema associated with pneumothorax in- directly after tube insertion, but can be added after
volves an air filled space, not formerly in communication with 48 hours for persistent air leak or failure of a
the subcutaneous tissue, being brought into communication pneumothorax to re-expand. [B]
with the subcutaneous tissues. This may occur in the presence
of a malpositioned, kinked, blocked, or clamped tube. • High volume, low pressure (–10 to –20 cm H2O)
Likewise, a small tube in the presence of a very large leak may suction systems are recommended. [C]
potentially cause surgical emphysema. Occasionally, the • Patients requiring suction should only be managed
resulting acute airway obstruction or thoracic compression on lung units where there is specialist medical and
may lead to respiratory compromise.78 79 The treatment is nursing experience. [C]
usually conservative but, in life threatening situations, There is no evidence to support the routine initial use of suc-
tracheostomy, skin incision decompression, and insertion of tion applied to chest drain systems in the treatment of spon-
large bore modified subcutaneous chest drains have all been taneous pneumothorax.80 85 A persistent air leak, with or with-
used.78 out incomplete re-expansion of the pneumothorax on a chest
4.3.2 Size of tube radiograph, is the usual reason for applying suction to an
intercostal tube system. A persistent air leak is usually
• There is no evidence that large tubes (20–24 F) are arbitrarily defined as a continued air bubbling through an
any better than small tubes (10–14 F) in the manage- intercostal tube 48 hours after insertion. Mathur and
ment of pneumothoraces. The initial use of large colleagues86 retrospectively reviewed 142 cases of spontaneous
(20–24 F) intercostal tubes is not recommended, pneumothorax requiring chest drain insertion. The median
although it may become necessary to replace a small time to resolution was 8 days (19 days in those with
chest tube with a larger one if there is a persistent air underlying lung disease), which was not related to the initial
leak. [B] size of the pneumothorax. Most of the patients (30/43) with a
Although one study suggested that success rates for the treat- persistent air leak had suction applied, but without standardi-
ment of pneumothoraces with small chest tubes (13 F) were sation of the degree of suction or of the point of initiation (the
poor and that larger sized catheters should be used,80 first 4 days in the majority). Normal intrapleural pressures are
subsequent studies have not confirmed this and suggest that –8 cm H2O during inspiration and –3.4 cm H2O during expira-
smaller calibre chest tubes are just as effective.81–84 Primary tion. During intercostal tube drainage various factors influ-
success rates of 84–97% were recorded in these studies using ence the amount of suction applied to the pleural space.63 87 It
drains of 7–9 F gauge. Recent technical developments have has been suggested that, because the magnitude of these
allowed the addition of a Heimlich flutter valve to small tubes physiological factors varies, it is desirable to apply –10 to
as well as to larger bore tubes. –20 cm H2O suction to all pneumothoraces which are slow to
Factors which might predispose to small tube failure, thus re-expand, and the system used should have the capacity to
favouring the choice of a larger tube, would be the presence of increase the suction with an air flow volume of 15–20 l/min.88
pleural fluid and the presence of a large air leak which exceeds Over 40 years ago Roe89 stressed the importance of high
the capacity of the smaller tubes.82 The use of an indwelling volume vacuums to drain the pleural space during pneumot-
small lumen Teflon catheter (2 mm) inserted “over needle and horaces. The use of high pressure, high volume suction is not,
guidewire” attached to a flutter valve after partial aspiration however, recommended because of the ease with which it can
with a 60 ml syringe proved successful in 27 of 28 patients generate high air flow suction which may lead to air stealing,
with a mean drainage time of 48 hours.59 Using a small calibre hypoxaemia, or the perpetuation of persistent air leaks.90 Like-
chest drain system, the median duration of drainage ranged wise, high pressure, low volume systems should be avoided.64
from 2 to 4 days, which compares very favourably with larger High volume, low pressure systems such as a Vernon-
intercostal tube drainage systems.59 82 83 Difficulties with tube Thompson pump or wall suction with an adaptor to reduce
blockage were not encountered in any of these studies. pressure are recommended. Unfortunately, due to the lack of
Chemical pleurodesis is still possible through smaller tubes more recent randomised controlled trials examining the role
including indwelling catheter systems. of suction with intercostal tube systems, evidence based
If the decision is made to insert a chest drain, small recommendations cannot be applied. The best practice from
(10–14 F) systems should be used initially. The use of catheter previous studies to date, as above, suggests that suction should
over guidewire systems (Seldinger technique) may prove to be be applied after 48 hours, but that surgical referral for a
as safe and effective as small calibre tubes, although they are persistent air leak in those without pre-existing lung disease
more expensive. They are being used with increasing should be made at 5–7 days. Significantly, earlier referral (2–4
frequency, but further evidence is required before they can be days) should be considered in those with underlying disease,
recommended for initial use. a large persistent air leak, or failure of the lung to
re-expand.91–93 If suction is to be applied to a chest drain, it is
4.4 Referral to respiratory specialists
recommended that the patient should be situated in an area
• Pneumothoraces which fail to respond within 48 where specialist nursing experience is available.
hours to treatment should be referred to a respira- The addition of suction too early after the insertion of a
tory physician. [C] chest tube, particularly in the case of a primary pneumo-
Failure of a pneumothorax to re-expand or a persistent air leak thorax which may have been present for a few days, may
exceeding 48 hours duration should prompt referral to a res- precipitate re-expansion pulmonary oedema (RPO) and is
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ii46 Henry, Arnold, Harvey
contraindicated. RPO is probably caused by the increased per- pleurodesis.97 99 103 Large randomised controlled studies com-
meability of capillaries damaged during a pneumothorax. This paring the use of tetracycline as a sclerosant with standard
becomes manifest as oedema during re-expansion due to fur- management in primary pneumothorax are needed to
ther mechanical stresses applied to the already “leaky” determine whether or not tetracycline should be used after
capillaries.94 Clinically, these patients manifest symptoms of treatment of a first uncomplicated primary pneumothorax to
coughing and breathlessness or chest tightness after insertion prevent recurrence. Tetracycline can, however, be recom-
of the chest tube. In those whose symptoms persist, a repeat mended for recurrent primary pneumothorax and secondary
chest radiograph after 24 hours will often show pulmonary pneumothorax when surgery is not an option, and talc may be
oedema in the treated lung, although pulmonary oedema may used on the grounds that it is the most effective agent in
also develop in the contralateral lung.95 The incidence of RPO malignant effusion. There is conflicting evidence as to whether
may be up to 14% and is higher in those with larger primary tetracycline is effective for the treatment of fully expanded
pneumothoraces and in younger patients (<30 years), pneumothorax with persistent air leak.36 106 107 The largest of
although in most cases RPO does not progress beyond a radio- these studies, the Veterans Administration Study, did not sup-
logical phenomenon.96 However, the clinical relevance of RPO port the use of intrapleural tetracycline to facilitate the closure
must not be understated as the outcome has been reported as of a persistent air leak.36 Macoviak and colleagues107 suggest
fatal in 20% of 53 reported cases who developed a clinical that intrapleural tetracycline can facilitate the closure of a
deterioration as part of an RPO syndrome in one series.95 Par- persistent air leak provided that the lung can be kept
ticular caution should therefore be exercised in treating young expanded so that symphysis can occur. Likewise, there is con-
patients with large pneumothoraces and suction should not be flicting evidence as to whether intrapleural tetracycline short-
used immediately in the treatment of a spontaneous ens the length of stay in hospital with pneumothorax.36 97 103
pneumothorax. Even when employed later and it is suspected The dosage of intrapleural tetracycline requires clarifica-
that the pneumothorax has been present for a considerable tion. Almind et al97 found a reduction in the incidence of
period of time, the potential development of RPO should be recurrence in a group receiving 500 mg tetracyline via chest
considered.96 drains compared with those treated by tube drainage alone.
This reduction was not significant. The Veterans Administra-
4.4.2 Chemical pleurodesis tion Study,36 which used 1500 mg tetracycline, showed a
significant reduction in the incidence of recurrence of
• Chemical pleurodesis can control difficult or recur- pneumothorax without significant extra morbidity. This dose
rent pneumothorax [A] but should only be at- of intrapleural tetracycline is therefore recommended as the
tempted if the patient is either unwilling or unable to standard dose for medical pleurodesis. While pain was
undergo surgery. [B] reported more frequently in the group treated with tetracy-
• Medical pleurodesis for pneumothorax should be cline at a dose of 1500 mg,36 others have reported no increase
performed by a respiratory specialist. [C] in pain with tetracycline at a dose of 500 mg provided
Chemical pleurodesis has generally been advocated by chest adequate analgesia is given.97 Adequate analgesia may be
physicians experienced in thoracoscopy. The instillation of achieved with administration of intrapleural local anaesthe-
substances into the pleural space should lead to an aseptic sia. Standard doses (200 mg (20 ml) 1% lignocaine) are
inflammation with dense adhesions, leading ultimately to significantly less effective than larger doses (250 mg (25 ml)
pleural symphysis. There is a high rate of recurrence of 1% lignocaine). The higher doses have been shown to increase
primary and secondary pneumothoraces,14 and efforts to the number of pain free episodes from 10% to 70% with no
reduce these rates by instillation of various sclerosants— appreciable toxicity.68
either via chest drains or by surgical means—are regularly Medical and surgical pleurodesis using talc remain effective
alternatives to tetracycline pleurodesis. There are no control-
undertaken without clear guidelines to direct physicians in
led trials comparing talc and tetracycline as sclerosants in the
their use. In the majority of cases, when appropriate, the pre-
treatment of pneumothorax. The issue of talc pleurodesis will
vention of further pneumothoraces should be undertaken by
be dealt with later in the surgical section of this review as most
surgical means. The rate of recurrence of pneumothoraces
trials using talc tend to focus on surgical talc pleurodesis.
after surgical intervention either by thoracotomy or VATS,
Since medical pleurodesis is recognised to be “second best”
with or without surgical pleurodesis, is far less than after
care and its use will imply a “difficult” case, it is recommended
medical pleurodesis.36 97–99 A small number of individuals are
that medical pleurodesis be undertaken only by respiratory
either too frail or are unwilling to undergo any definitive sur-
specialists or thoracic surgeons.
gical treatment to prevent recurrence of their pneumothoraces
and, in these instances, medical chemical pleurodesis may be 4.5 Referral to thoracic surgeons
appropriate.
• In cases of persistent air leak or failure of the lung to
During the last decade many sclerosing agents have been
re-expand, the managing respiratory specialist
studied.36 97 100–103 Tetracycline is recommended as the first line
should seek an early (3–5 days) thoracic surgical
sclerosant therapy in both primary and secondary pneumo-
opinion. [C]
thoraces. It was initially proposed as it proved to be the most
effective sclerosant in animal models.101 104 105 Recently, • Open thoracotomy and pleurectomy remains the
parenteral tetracycline for pleurodesis has become more diffi- procedure with the lowest recurrence rate for
cult to obtain due to problems with the manufacturing proc- difficult or recurrent pneumothoraces. Minimally
ess. The parenteral preparation is currently available in invasive procedures, thoracoscopy (VATS), pleural
Germany and may be imported via international wholesalers. abrasion, and surgical talc pleurodesis are all effec-
These suppliers state that supplies are expected to remain tive alternative strategies.
available for the foreseeable future. Minocycline and doxy- The timing of surgical intervention for pneumothorax has
cycline have been shown to be reasonable alternatives as recently been challenged and remains contentious. There is no
sclerosants in animal models.104 105 evidence based justification for the arbitrary but widely advo-
The rate of recurrence of pneumothorax is the primary cated cut off point of 5 days for surgery for a persistent air
indicator of success for any sclerosant. Although tetracycline leak.48 Chee and colleagues108 showed that 100% of primary
has been shown significantly to reduce the incidence of early pneumothoraces treated by tube drainage with persistent air
recurrence, the incidence of late recurrence is 10–20% which is leaks for more than 7 days had resolved their air leaks by 14
unacceptably high compared with surgical methods of days and 79% of those with secondary pneumothoraces and
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BTS guidelines for the management of spontaneous pneumothorax ii47
persistent air leaks had resolved their air leaks by 14 days with alisation of the visceral pleura. This may not be possible dur-
no mortality. However, considering the efficacy and relatively ing a VATS procedure, increasing the risk of missing a leaking
low levels of morbidity and recurrence associated with surgery bulla.121–123 Open thoracotomy may be associated with in-
for pneumothorax,109–112 earlier surgical intervention has been creased postoperative respiratory dysfunction and hospital
advocated for persistent air leak or failure of re-expansion, stay compared with VATS procedures.120 It is suggested that the
particularly in cases of secondary pneumothorax.92 113 Several success rates with the open procedure are higher.124 Thus, sur-
authors have recommended operative referral/intervention as gical authorities suggest open thoracotomy in patients with
early as 3 days for a persistent air leak. However, these studies secondary pneumothoraces who may have extensive pleural
were not controlled.91 93 Despite the reduction in the incidence disease requiring more extensive pleurectomy, subpleural
of late recurrence of pneumothorax in many of these studies, bullectomy, or pleural abrasion.110 114 125
surgical referral for a persistent air leak in a first primary
pneumothorax within the first 4–5 days is not supported by Surgical chemical pleurodesis
the literature. However, best practice suggests that protracted
• Surgical chemical pleurodesis is best achieved with
chest tube drainage is not in the patient’s interest. It is there-
5 g sterile talc. Side effects such as ARDS and
fore recommended that patients with difficult pneumothora-
empyema are reported but rare. [A]
ces should receive care from a respiratory physician and that a
thoracic surgical opinion will be an early part of management. The use of talc pleurodesis is now a subject of renewed inter-
According to the statistical and perceived risk of recurrence, est because of the potential unavailability of tetracycline, its
accepted indications for operative intervention are as follows: low cost, and a record of successful pleurodesis (85–92%) that
• Second ipsilateral pneumothorax is similar to alternative thoracoscopic techniques for compli-
cated pneumothorax.99 114 126 127 While talc slurry inserted under
• First contralateral pneumothorax medical supervision via intercostal tube drainage tends to be
• Bilateral spontaneous pneumothorax less favoured than thoracoscopic talc poudrage, both methods
• Persistent air leak (>5–7 days of tube drainage; air leak or have been shown to be effective. The overall success rate for
failure to completely re-expand) talc pleurodesis reviewed by meta-analysis is 91%.126 Surgical
pleurodesis with tetracycline is not generally felt to be a satis-
• Spontaneous haemothorax
factory alternative, with recurrence rates of 16% in a series of
• Professions at risk (e.g. pilots, divers)108 110 114–116 390 patients who underwent surgical pleurodesis using
tetracycline.98 There are no controlled trials comparing pain
4.5.1 Surgical strategies
during talc pleurodesis with that using other agents, although
There are two objectives in the surgical management of a
it is suggested that talc pleurodesis is no more difficult or
pneumothorax. The first widely accepted objective is resection
painful a procedure than tetracycline pleurodesis.128–132 Dos-
of blebs or the suture of apical perforations to treat the under-
ages of talc ranging from 2 g to 10 g have been used, but the
lying defect. The second objective is to create a pleural
suggestion that higher dosages are more effective has not been
symphysis to prevent recurrences. There is debate between
established by controlled trials. On the basis of a meta-
those who favour surgical pleurodesis or pleural abrasion ver-
analysis of uncontrolled data, 5 g talc by VATS is recom-
sus those who favour partial or total pleurectomy as a defini-
mended with a success rate of 87%, which is very close to the
tive treatment to prevent recurrence of pneumothorax,109 117 118
success rates using more extensive operative approaches.126
although a relatively recent comprehensive review of this area
Side effects reported with talc pleurodesis include five cases of
suggests a slight advantage of pleurectomy over pleural abra-
adult respiratory distress syndrome (ARDS), although the risk
sion with a recurrence rate of 0.4% after pleurectomy (n=752)
of ARDS may be related to the size of talc particles used133;
and 2.3% after pleural abrasion (n=301).109 Operative tech-
empyema, although this is rare when properly sterilised talc is
niques have tended towards minimally invasive procedures
used126 134 135; pneumonia; and respiratory failure.134 In view of
over the last few years. In order to be considered effective,
these potential side effects, standard first line usage of talc
these techniques should yield results comparable to the “gold
poudrage or talc slurry pleurodesis should be approached with
standard” open thoracotomy procedure—that is, the operative
caution since surgery not dependent on introducing a foreign
morbidity should be less than 15% and the pneumothorax
agent is usually an option. Lower dosages of 2–5 g should be
recurrence rate should be less than 1%.37 99 112
used until dosage schedules and effectiveness have been clari-
Open thoracotomy fied. Long term safety does not appear to be an issue if
In 1941 Tyson and Crandall119 described pleural abrasion as a asbestos-free talc is used. The success rates with talc poudrage
treatment for pneumothorax and in 1956 Gaensler117 intro- and talc slurry pleurodesis are similar, so either approach can
duced parietal pleurectomy for recurrent pneumothorax. This be recommended. Because of the relatively high failure rates
procedure produces uniform adhesions between the pleura of over 9% with talc pleurodesis compared with surgical pleu-
and the chest wall. Both of these techniques are designed to ral stripping procedures, talc pleurodesis should not be
obliterate the pleural space by creating symphysis between the considered as initial treatment for primary spontaneous
two pleural layers or between the visceral pleura and subpleu- pneumothorax requiring surgical intervention. In those
ral plane, in the case of parietal pleurectomy. In order to pre- patients who are either unwilling or too unwell to undergo
vent recurrence, however, an appropriate closure at the site of general anaesthesia, medical pleurodesis with either tetra-
the pleural air leak is essential either by cauterisation, ligation, cycline or talc (via an intercostal tube) is recommended.
or suture of accompanying blebs.116 Open thoracotomy yields
the lowest postoperative recurrence results. Bulla ligation/ Transaxillary minithoracotomy
excision, thoracotomy with pleural abrasion, and either apical Becker and Munro136 pioneered this technique in the 1970s.
or total parietal pleurectomy all have failure rates under The procedure is considered a minimally invasive procedure.
0.5%.48 110 Morbidity from thoracotomy for pneumothorax has The incision in the axillary margin measures 5–6 cm. Apical
an overall incidence of 3.7%, mostly in the form of sputum pleurectomy or abrasion may be performed and the apex care-
retention and postoperative infection.110 Open thoracotomy is fully inspected for pleural blebs or bullae which may be
generally performed using single lung ventilation, a limited stapled. The largest series examining this technique reported
posterolateral thoracotomy allowing parietal pleurectomy, a mean hospital stay of 6 days, a recurrence rate of 0.4%, and
excision, or stapling of bullae or pleural abrasion.120 Isolated a complication rate of 10%, most of which were minor.125 These
lung ventilation during open thoracotomy facilitates full visu- results make this procedure a realistic alternative to open
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ii48 Henry, Arnold, Harvey
thoracotomy for the treatment of complicated spontaneous closed pneumothorax should not travel on a commercial
pneumothorax. flight. There is no evidence that air travel precipitates
recurrence of a pneumothorax, but recurrence during a flight
Video assisted thoracoscopic surgery (VATS) may have serious repercussions. The BTS Air Travel Working
The evaluation of VATS for spontaneous pneumothorax is lim- Party stress that patients may travel safely 6 weeks after a
ited by the small number of randomised trials comparing it definitive surgical procedure or resolution of the pneumotho-
with alternative surgical approaches. To date, there have only rax on the chest radiograph. Otherwise, there is still a signifi-
been two randomised studies which have attempted to define cant risk of recurrence for up to 1 year, depending on whether
the role of VATS in the treatment of spontaneous the patient has underlying lung disease or not. Patients,
pneumothorax.120 137 In a comprehensive review, Massard and particularly those who have suffered a secondary spontaneous
colleagues99 have suggested that the impression that VATS is pneumothorax, may decide to avoid the risk by avoiding flying
superior to open procedures in terms of morbidity, time in for a year in the absence of a definitive surgical procedure.147
hospital, and cost may not be wholly correct. Minimally After a pneumothorax, diving should be discouraged perma-
invasive surgery may have a complication rate similar to open nently unless a very secure definitive prevention strategy such
procedures at about 8–10%.120 122 138 Recurrence rates of as surgical pleurectomy has been performed.148 The BTS
pneumothorax after VATS are 5–10%,114 127 which are higher guidelines on respiratory aspects of fitness for diving149 deal
than the 1% rates reported after open procedures.110 While with this in greater detail.
bullectomy, pleurectomy, pleural abrasion, and surgical pleu- Patients with primary pneumothorax treated successfully
rodesis have all been shown to have reasonable success rates by simple aspiration should be observed to ensure clinical sta-
when carried out thoracoscopically,120 122 128 139–141 there are con- bility before discharge. The few patients with secondary
cerns associated with VATS performed under local anaesthetic pneumothorax who are successfully treated with simple aspi-
supplemented by nitrous oxide inhalation. These arise from ration should be admitted at least overnight and preferably for
the inability to obtain isolated single lung ventilation and 24 hours before discharge to ensure no recurrence. The
include difficulties in inspecting the entire visceral pleural mortality rate associated with secondary pneumothorax is
surface, increasing the risk of missing a leaking bleb or 10%, and many of these patients die after the pneumothorax
bulla.123 142 It is also suggested that a less intense pleural has resolved.18 32 Most patients with secondary pneumothorax
inflammatory reaction is induced by VATS procedures leading will require a more protracted admission, including treatment
to a less effective pleurodesis.143 Several authors suggest that of their underlying lung disorder.32 All patients discharged
VATS offers significant advantages over open thoracotomy after active treatment or otherwise should be given verbal and
including a shorter postoperative hospital stay,114 120 127 138 142 written advice to return to the Accident and Emergency
significantly less postoperative pain,120 125 143 144 and better department immediately should they develop further breath-
pulmonary gas exchange in the postoperative period.145 How- lessness.
ever, Kim and colleagues in their randomised controlled trial
did not confirm a shorter postoperative stay in the VATS
5 PNEUMOTHORAX AND AIDS
groups.137
Further randomised trials comparing VATS with transaxil- • Early and aggressive treatment of pneumothoraces
lary and open thoracotomies are required and, until these data in HIV patients, incorporating intercostal tube
are available, VATS cannot be considered to be established as drainage and early surgical referral, is recommended.
being superior to thoracotomy.144 Waller and colleagues146 sug- [B]
gested that, while VATS may be the preferred surgical There is evidence that the clinical spectrum of spontaneous
procedure for young fit people with complicated or recurrent pneumothorax is shifting away from the predominant
primary pneumothoraces, it is less reliable in cases of second- subpleural bleb disease as emphasised by most reports since
ary pneumothorax. In cases of secondary pneumothorax, open Kjaergard.3 There are several reports that up to 25% of sponta-
thoracotomy and repair is still the recommended approach neous pneumothoraces in large urban settings with a high
and VATS procedures should be reserved for those who might prevalence of HIV infection are AIDS related31 32 150; 2–5% of
not tolerate an open procedure because of poor lung function. AIDS patients will develop a pneumothorax.151–153 Pneumocystis
carinii infection should be considered as the most likely
4.6 Discharge and follow up aetiology in any HIV positive patient who develops a
• Patients discharged without intervention should pneumothorax, although the administration of aerosolised
avoid air travel until a chest radiograph has con- pentamidine has also been suggested as an independent risk
firmed resolution of the pneumothorax. [C] factor.151 Pneumocystis carinii pneumonia (PCP) is associated
with a severe form of necrotising alveolitis in which the sub-
• Diving should be permanently avoided after a pneu-
pleural pulmonary parenchyma is replaced by necrotic thin
mothorax, unless the patient has had bilateral surgi-
walled cysts and pneumatoceles.154 155 AIDS related spontane-
cal pleurectomy. [C]
ous pneumothorax is complicated by the refractory nature of
• Primary pneumothorax patients treated successfully air leaks which tend to occur with the necrotising subpleural
by simple aspiration should be observed to ensure pneumonitis of PCP infection.156 Such is the relationship
clinical stability before discharge. Secondary pneu- between AIDS related pneumothorax and the presence of P
mothorax patients who are successfully treated with carinii that the occurrence of pneumothorax in AIDS patients
simple aspiration should be admitted for 24 hours is considered an indicator of treatment for active P carinii
before discharge to ensure no recurrence. [C] infection.151 AIDS related spontaneous pneumothorax carries
Patients with spontaneous pneumothoraces who are dis- a higher hospital mortality, a higher incidence of bilateral
charged without active intervention should be advised to (40%) and recurrent pneumothoraces, and more prolonged air
return for a follow up chest radiograph after 2 weeks. These leaks.157 Treatment failures may also reflect the degree of
patients should be cautioned against flying until a follow up immunocompromise of the impaired host as reflected by the
chest radiograph confirms full resolution of the pneumotho- CD4 counts.157 It has also been suggested that systemic
rax. Commercial airlines currently arbitrarily advise that there corticosteroids used to treat PCP may increase the risk of mor-
should be a 6 week interval between having a pneumothorax bidity from AIDS related pneumothorax.158 Because of the
and travelling by air. A recent chest radiograph should confirm high rate of primary treatment failures and associated short
resolution of the pneumothorax. A patient with a current survival times reported for such patients,159 160 early and
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BTS guidelines for the management of spontaneous pneumothorax ii49
aggressive treatment of AIDS related spontaneous high concentration oxygen and a cannula should be intro-
pneumothorax—incorporating early tube drainage and talc duced into the pleural space, usually in the second anterior
pleurodesis, early VATS assisted talc poudrage, unilateral or intercostal space mid clavicular line. Air should be removed
bilateral pleurectomy—is recommended.150 152 157 158 161 162 until the patient is no longer compromised and then an inter-
costal tube should be inserted into the pleural space as previ-
6 PNEUMOTHORAX AND CYSTIC FIBROSIS ously described. Advanced Trauma Life Support guidelines
recommend the use of a cannula 3–6 cm long to perform
• Early and aggressive treatment of pneumothoraces needle thoracocentesis for life threatening tension
in cystic fibrosis is recommended. [C] pneumothorax.172 However, in 57% of patients with tension
• Surgical intervention should be considered after the pneumothorax the thickness of the chest wall has been found
first episode, provided the patient is fit for the proce- to be greater than 3 cm. It is therefore recommended that a
dure. [C] cannula length of at least 4.5 cm should be used in needle
The treatment of pneumothorax for patients with cystic fibro- thoracocentesis of tension pneumothoraces.173 174 The cannula
sis (CF) is similar to that for non-CF patients. A pneumotho- should be left in place until bubbling is confirmed in the
rax is associated with more severe disease and can be life underwater seal system to confirm proper function of the
threatening. Median survival after pneumothorax in patients intercostal tube.169
with CF is 30 months and the occurrence reflects the severity
of the underlying disease rather than being an independent 8 IATROGENIC PNEUMOTHORAX
risk factor.163 Contralateral pneumothoraces occur in up to 40% The incidence of iatrogenic pneumothorax is high, outnum-
of patients.163 164 A small pneumothorax without symptoms bering spontaneous pneumothoraces in several large review
can be observed or aspirated. Larger pneumothoraces require series.175 176 Transthoracic needle aspiration (24%), subclavian
treatment with intercostal tube drainage. The leak is usually vessel puncture (22%), thoracocentesis (22%), pleural biopsy
from the upper lobes and it is important to site the tube in the (8%), and mechanical ventilation (7%) are the five leading
correct place. The collapsed lung can be stiff and take a long causes.173 The two primary risk factors related to the develop-
time to re-expand. It is important to commence intravenous ment of pneumothorax with transthoracic needle aspiration
antibiotics at the same time to prevent sputum retention, are the depth of the lesion and the presence of COPD.177 To
which can delay re-expansion of the collapsed lung. Pleurec- date, no method has been found to prevent pneumothorax
tomy, pleural abrasion, and talc pleurodesis all have markedly following needle aspiration/thoracocentesis. While it was
lower reported recurrence rates than observation or tube tho- hoped that positioning the patient so that the area to be biop-
racostomy alone, which has an unacceptably high recurrence sied was dependent might reduce the incidence of such
rate of 50%.165–167 Partial pleurectomy has a success rate of 95% events, this has not been shown to be the case.178 The
with little reduction in pulmonary function associated with treatment of iatrogenic pneumothorax tends to be simple as
surgery, and it is generally felt to be the treatment of choice in there is less likelihood of recurrence. The majority will resolve
CF patients with recurrent pneumothoraces who are fit to with observation alone. If required, treatment should be by
undergo surgery.163 In those patients who are too ill to undergo simple aspiration. Delius and coworkers58 aspirated up to 89%
surgery, it can take 2–3 weeks for the lung to re-expand with without resorting to tube drainage using a small 8 F teflon
intubation and suction. In this group, talc instillation or catheter. Patients with COPD who develop an iatrogenic
repeated instillation of the patient’s own blood are effective pneumothorax are more likely to require tube drainage,179 and
alternatives.163 Although not an absolute contraindication to patients who develop a pneumothorax while on positive pres-
transplantation, sclerosants can make transplantation more sure ventilation should be treated with a chest drain unless
difficult. It takes longer to remove the lungs, prolonging the immediate weaning from positive pressure ventilation is pos-
ischaemic time for the donor lungs, and is associated with sible, as positive pressure ventilation maintains the air leak.180
excessive bleeding.168
9 CONCLUDING REMARKS
7 TENSION PNEUMOTHORAX The 1993 BTS pneumothorax guidelines emphasised the place
of simple observation and aspiration, reminded junior doctors
• If tension pneumothorax is present, a cannula of of the potential hazards of chest drain insertion, and encour-
adequate length should be promptly inserted into aged shorter, safer and less painful treatment paths for many
the second intercostal space in the mid clavicular line patients. Despite their usefulness, recent evidence suggests
and left in place until a functioning intercostal tube that adherence to these guidelines may be suboptimal. This
can be positioned. [B] revision endorses the main thrust of these guidelines, with
Tension pneumothorax occurs when the intrapleural pressure observation for the least severe cases, simple aspiration as the
exceeds the atmospheric pressure throughout inspiration as initial treatment choice, and chest drain insertion as a last
well as expiration. It is thought to result from the operation of resort. Recently, the American College of Chest Physicians
a one way valve system, drawing air into the pleural space (ACCP) has published its own guidelines which were arrived
during inspiration and not allowing it out during expiration. at by the Delphi consensus method.65 These guidelines are
The development of tension pneumothorax is often, but not similar to our proposed guidelines in many respects, although
always, heralded by a sudden deterioration in the cardiopul- there are differences such as the emphasis placed on the value
monary status of the patient related to impaired venous of simple aspiration in the treatment of primary pneumotho-
return, reduced cardiac output, and hypoxaemia.169 170 The rax. Both sets of guidelines will undoubtedly stimulate debate.
development of tension in a pneumothorax is not dependent The evidence for the current BTS recommendations is
on the size of the pneumothorax and the clinical scenario of incorporated and its weaknesses described. This revision alters
tension pneumothorax may correlate poorly with chest radio- the threshold for aspiration in primary pneumothorax and
graphic findings. The clinical status is striking. The patient suggests a place for re-aspiration. The limitations of aspiration
rapidly becomes distressed with rapid laboured respiration, in secondary pneumothorax are acknowledged, and initial
cyanosis, sweating, and tachycardia. It should be particularly chest drain insertion is recommended for categories of
suspected in those on mechanical ventilators or nasal patients where aspiration is unlikely to succeed. These issues
non-invasive ventilation who suddenly deteriorate or develop are already being revisited as the new “pneumothorax kits”
EMD arrest, and is frequently missed in the ICU setting.171 If a inserted with a Seldinger technique and containing integral
tension pneumothorax occurs, the patient should be given Heimlich type flutter valves gain popularity. It is likely that
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